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All cats are not gray; all pain programs are not alike
PAIN 01520
All cats are not gray; all pain programs Alan
are not alike
H. Roberts
DIV.of Medical P.yychologv, Scrrpps Clime and Research Foundation, IO066 North Ton-q Pmes Road, L.u Jolla CA 92037 (U.S.A.) (Received
31 May 1989, accepted
Dear Editor. The recent article by Gallon (Pain, 37 (1989) 67-75) was interesting and provided some useful data concerning long-term outcomes for a pain treatment program at a medical center in Bangor, ME. Quality long-term follow-up studies of this kind are desirable and should be encouraged. His report, however, calls attention to a common tendency for researchers and reviewers alike to think about and write about all pain programs as if they were the same. In comparing outcomes among pain programs, reports seem to assume that all pain programs use the same methods, that chronic pain patients constitute a homogeneous population to be treated similarly, and that the quality of the treatment provided is similar among programs. It is obvious, when so stated, that these assumptions are not correct, but many who compare outcomes among programs seem to make these assumptions implicitly. Gallon, for example, compares the long-term outcomes for his 300 chronic back pain patients with reports from other programs treating different populations of patients by methods which probably differ from his, either qualitatively or quantitatively. Pain is a symptom, not a disease; chronic pain is not a disease either, it is a syndrome. The etiology of chronic pain varies from patient to patient; thus, its treatment may also need to be varied from patient to patient. When reviewing reports of treatment programs it becomes clear that some attempt to confine interventions to operant behavioral techniques 0304-3959/89/$03.50
C 1989 Elsevier Science Publishers
1 August
1989)
(‘behavioral programs’). Other programs incorporate or emphasize a variety of other interventions (‘multi-modal programs’) which may include biofeedback, physical therapy modalities (ultrasound, massage, etc.), or psychological treatments (group therapy, coping skills training, cognitive therapy, hypnotherapy, relaxation training, etc.). Some are medically oriented and provide techniques from anesthesiology and other medical or surgical specialties. Some programs work with families, others do not. Some are inpatient and others outpatient. Length of treatment may vary from a few days to eight weeks or longer. It has been speculated that the use of some treatment modalities may reinforce pain behaviors and thus reduce program effectiveness. The population treated also varies from program to program. Sources of referral may differ. Pain etiologies may differ. Some patients may request treatment while others may be sent with variable motivation. Pending litigation or compensation remains an unresolved issue (partly because all compensation/litigation patients are not the same just as all pain patients are not the same) and this too may differ from program to program. Some programs accept all who apply; others are selective and will accept only those they believe will profit. Behavioral program outcomes are extremely sensitive to staff composition, communication skills and the ability of staff to consistently apply behavioral principles to patients who are sometimes angry or manipulative. Skilled social workers teaching families to apply behavioral principles in
B.V. (Biornedlcal
Division)
369
supportive ways can make a profound difference in outcome when compared to programs that do not provide or emphasize this kind of service. Gallon, in his report, does not describe his program or his patients in enough detail to understand why the results of his program (only 29% of his patients reported themselves as improving) differ so sharply from the reports of Roberts and Reinehart (Pain, 8 (1980) 151-162) who reported 77% of an extremely chronic and disabled population to be functioning at ‘normal’ levels according to objective criteria on follow-ups up to 8 years post treatment. The same discrepancies occur in other outcome studies; this problem is not Gallon’s alone but is epidemic in the chronic pain literature.
The answer to these problems seems obvious. While all cats appear to be gray in the dark, shedding more light on the characteristics of treatment programs reported should provide an array of colourful differences, both qualitative and quantitative, among programs. Until researchers describe their treatment patients in enough detail, we will not know why or how program outcomes differ from one treatment program to another. We are then deprived of the opportunity to determine what kinds of programs and what dimensions of programs are most effective in helping to rehabilitate patients with chronic pain.
All cats are not gray; all pain programs Alan
are not alike
H. Roberts
DIV.of Medical P.yychologv, Scrrpps Clime and Research Foundation, IO066 North Ton-q Pmes Road, L.u Jolla CA 92037 (U.S.A.) (Received
31 May 1989, accepted
Dear Editor. The recent article by Gallon (Pain, 37 (1989) 67-75) was interesting and provided some useful data concerning long-term outcomes for a pain treatment program at a medical center in Bangor, ME. Quality long-term follow-up studies of this kind are desirable and should be encouraged. His report, however, calls attention to a common tendency for researchers and reviewers alike to think about and write about all pain programs as if they were the same. In comparing outcomes among pain programs, reports seem to assume that all pain programs use the same methods, that chronic pain patients constitute a homogeneous population to be treated similarly, and that the quality of the treatment provided is similar among programs. It is obvious, when so stated, that these assumptions are not correct, but many who compare outcomes among programs seem to make these assumptions implicitly. Gallon, for example, compares the long-term outcomes for his 300 chronic back pain patients with reports from other programs treating different populations of patients by methods which probably differ from his, either qualitatively or quantitatively. Pain is a symptom, not a disease; chronic pain is not a disease either, it is a syndrome. The etiology of chronic pain varies from patient to patient; thus, its treatment may also need to be varied from patient to patient. When reviewing reports of treatment programs it becomes clear that some attempt to confine interventions to operant behavioral techniques 0304-3959/89/$03.50
C 1989 Elsevier Science Publishers
1 August
1989)
(‘behavioral programs’). Other programs incorporate or emphasize a variety of other interventions (‘multi-modal programs’) which may include biofeedback, physical therapy modalities (ultrasound, massage, etc.), or psychological treatments (group therapy, coping skills training, cognitive therapy, hypnotherapy, relaxation training, etc.). Some are medically oriented and provide techniques from anesthesiology and other medical or surgical specialties. Some programs work with families, others do not. Some are inpatient and others outpatient. Length of treatment may vary from a few days to eight weeks or longer. It has been speculated that the use of some treatment modalities may reinforce pain behaviors and thus reduce program effectiveness. The population treated also varies from program to program. Sources of referral may differ. Pain etiologies may differ. Some patients may request treatment while others may be sent with variable motivation. Pending litigation or compensation remains an unresolved issue (partly because all compensation/litigation patients are not the same just as all pain patients are not the same) and this too may differ from program to program. Some programs accept all who apply; others are selective and will accept only those they believe will profit. Behavioral program outcomes are extremely sensitive to staff composition, communication skills and the ability of staff to consistently apply behavioral principles to patients who are sometimes angry or manipulative. Skilled social workers teaching families to apply behavioral principles in
B.V. (Biornedlcal
Division)
369
supportive ways can make a profound difference in outcome when compared to programs that do not provide or emphasize this kind of service. Gallon, in his report, does not describe his program or his patients in enough detail to understand why the results of his program (only 29% of his patients reported themselves as improving) differ so sharply from the reports of Roberts and Reinehart (Pain, 8 (1980) 151-162) who reported 77% of an extremely chronic and disabled population to be functioning at ‘normal’ levels according to objective criteria on follow-ups up to 8 years post treatment. The same discrepancies occur in other outcome studies; this problem is not Gallon’s alone but is epidemic in the chronic pain literature.
The answer to these problems seems obvious. While all cats appear to be gray in the dark, shedding more light on the characteristics of treatment programs reported should provide an array of colourful differences, both qualitative and quantitative, among programs. Until researchers describe their treatment patients in enough detail, we will not know why or how program outcomes differ from one treatment program to another. We are then deprived of the opportunity to determine what kinds of programs and what dimensions of programs are most effective in helping to rehabilitate patients with chronic pain.